By David S. Hilzenrath
Washington Post Staff Writer
Wednesday, July 22, 2009
The industry that helped scuttle health reform 15 years ago with its "Harry and Louise" ads is back, voicing support for a central element of the Obama administration's plans: making sure everyone is covered.
That does not mean the industry is backing the administration. Indeed, the leader of the insurance lobby has sent lawmakers a message: Be careful what you change, because "77 percent of Americans are satisfied with their existing health insurance coverage."
Karen Ignagni, president of America's Health Insurance Plans (AHIP), invoked the statistic to argue against the creation of a government-run insurance option. But the polls are not that simple, and her assertion reveals how the industry's effort to defend its turf has led it to cherry-pick the facts.
The poll Ignagni was citing actually undercuts her position: By 72 to 20 percent, Americans favor the creation of a public plan, the June survey by the New York Times and CBS News found. People also said that they thought government would do a better job than private insurers of holding down health-care costs and providing coverage.
In addition, data from a Kaiser Family Foundation poll last year, compiled at the request of The Washington Post, suggest that the people who like their health plans the most are the people who use them the least.
Those who described their health as "excellent" -- people who presumably had relatively little experience pursuing medical care or submitting claims -- were almost twice as likely as those in good, fair or poor health to rate their private health insurance as excellent.
The level of satisfaction expressed with private insurance was essentially the same as that with Medicare, the government program for the elderly and disabled.
The industry's stance against a public health plan revives shades of 1994, when it was instrumental in blocking President Bill Clinton's health-care proposals.
"A government-run plan would turn back the clock on efforts to improve the quality and safety of patient care," AHIP has argued. Such a plan "will ultimately limit choices and access," the big insurer WellPoint contends.
But systemic problems have persisted for 15 years, and it is not clear how much private insurers have done, or can do, to solve them.
"Insurers promise choice, they promise innovation, they promise a lot of things, but I think they've delivered very little," said Alan Sager, professor of health policy and management at Boston University. "I think net they give us very bad value for the 10 to 20 percent share of the health dollar they skim off the top."
Instead of choice, they offer "the illusion of choice," he said.
Health-care costs have continued to rise faster than personal incomes and economic growth. Even the industry agrees that much of the spending is wasted, exposing patients to unnecessary risk.
Insurers argue that a government plan could dominate the market, reducing consumers' options. But in the private market, options are limited by employers who restrict employees' choice of insurers and by insurers who restrict their choice of doctors.
Cigna, one of the nation's largest insurers, took away its own employees' alternatives in 2006 and left them with only high-deductible coverage.
"There were a lot of unhappy people," said Wendell Potter, who until last year was Cigna's head of corporate communications. For many people enrolled in such plans, "the deductibles are so high that they forgo care," he said.
Long a defender of the industry, Potter has become an outspoken critic of what he calls its "duplicitous" public relations and lobbying campaigns.
Few people have a better vantage point on the industry's efforts to improve quality and efficiency than Joseph P. Newhouse, professor of health policy and management at Harvard University, editor of the Journal of Health Economics and member of the board of insurance giant Aetna. Asked what results the industry's innovations have yielded, Newhouse said: "It's just very difficult to give much of an evidence-based answer to those questions . . . in either direction."
With respect to the disease-management programs the industry touts -- efforts to make sure people with chronic illnesses get the care they need -- "by and large, the literature suggests it works in some cases, but those cases are fairly limited," he said.
AHIP has produced a stack of glossy reports describing health insurers' efforts to improve care. In recent testimony, Ignagni said private health plans serving the elderly have been highly successful in reducing hospital admissions and readmissions for patients with diabetes and heart disease.
Yet one of the AHIP reports says that in an Aetna Pathways to Excellence hospital incentive program, "readmission rates did not improve significantly."
Opponents of a public option argue that it could put government bureaucrats between patients and doctors. Today, for people with commercial or employer-sponsored coverage, care is overseen by private bureaucracies. Where government bureaucracies answer to the body politic, the corporate versions answer to Wall Street.
The issue of whether a public plan would be more successful at bringing costs under control is harder to evaluate. As a prototype for government-run health care, Medicare has failed to control costs and makes little effort to restrict care.
Economists generally agree that if costs are to be brought under control, someone must say no to care that doctors propose and patients demand. So far, that role has fallen primarily to insurers.
"Private insurers have effectively engaged in rationing, so they're doing the dirty work for everybody else," said Jeff D. Emerson, a former health plan chief executive. "It's a thankless job . . . but somebody has to do it or health care will be even more expensive than it is now."
Private insurers might be better situated than the government to do the unpopular work of saying no, said Paul B. Ginsburg, president of the Center for Studying Health System Change, because they are less susceptible to political pressure.